Caitlin Register, Mercer University College of Pharmacy
According to the American Society of Addiction Medicine, opioid abuse continues to be a growing issue, and drug overdose is the leading cause of accidental death in the United States.  Between 1999 and 2008, opioid overdose death rates, prescription pain reliever sales, and substance use disorder treatment admissions increased in parallel.  Guidelines advise patients to remain active when able, and advise prescribers to consider use of non-pharmacologic therapy, including intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation.  Yoga combines physical postures, breathing techniques, and relaxation, and is considered to be a low-impact exercise technique with low risk of injury when guided by a trained instructor. In addition to chronic low back pain, it may reduce stress, lower blood pressure, and relieve anxiety, depression, and insomnia. 
|Yoga, Physical Therapy, or Education for Chronic Low Back Pain|
|Design||Single-blind, randomized, noninferiority; N= 320|
|Objective||To determine whether yoga is noninferior to physical therapy (PT) for chronic lower back pain (cLBP)|
|Study Groups||Weekly yoga classes (n= 127); PT visits (n= 129); educational book and newsletters (n= 64)|
|Methods||Adults with nonspecific cLBP were included, and all participants had access to usual medical care. The study consisted of two phases, a 12 week treatment phase, in which patients attended weekly yoga classes, PT visits, or received an educational book and newsletters, and a 40 week maintenance phase for yoga and PT groups. During the maintenance phase, yoga participants were randomly assigned to drop-in classes or home practice, and PT participants were randomly assigned to PT booster sessions or home practice. Back related function was measured by the Roland Morris Disability Questionnaire (RMDQ), a 23-point system with higher scores indicating worse function. Pain was measured using an 11-point numerical rating scale for average intensity in the previous week, where 0 indicated no pain and 10 indicated worst pain possible.|
|Primary Outcome Measures||Back-related function, and pain at 12 weeks|
|Secondary Outcome Measures||Pain medication use, global improvement, satisfaction with intervention, and health- related quality of life|
*Scores range from 0 to 100, with higher scores indicating better health-related quality of life
|Adverse Events||Common Adverse Events (yoga vs. PT vs. education, n): mild, self-limited joint and back pain (9 vs. 14 vs. 1)|
|Serious Adverse Events: N/A|
|Percentage that Discontinued due to Adverse Events: N/A|
|Study Author Conclusions||A manualized yoga program for nonspecific cLBP was noninferior to PT for improvement of back related function and pain. Both yoga and PT participants were more likely to have clinically meaningful functional improvements, but yoga was not found to be superior to education for both function and pain.|
While physical therapy is a standard recommendation for management of chronic low back pain, this study shows that yoga can be just as effective. This study not only showed yoga to be beneficial in pain management, but patients also reported an increase in physical health, mental health, and overall satisfaction. Yoga can be very cost efficient, as classes are offered throughout the United States through various organizations, as well as through pay per class programs. Additionally, many yoga resources including both education and videos can be found online for free. While this may not be the solution for all cases, it can open the door for many that do not have access to or funds for increased medication use or physical therapy.
 Opioid Addiction 2016 Facts & Figures. American Society of Addiction Medicine. www.asam.org. 2016.
 Paulozzi MD, Jones PharmD, Mack PhD, Rudd MSPH. Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Center for Disease Control and Prevention. 2011:60:5.
 Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
 Yoga: In Depth. U.S. Department of Health and Human Services: National Institutes of Health: National Center for Complementary and Integrative Health. nccih.nih.gov. June 2013.
 Saper RB, Lemaster C, Delitto A, et al. Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial. Ann Intern Med. 2017.